title: Severe and prolonged neurologic toxicity following subcutaneous chlorpyrifos self-administration: a case report.
abstract: BACKGROUND
  Organophosphate poisoning by oral or inhalation routes is characterized by a typical time-course of clinical features.
  
  
  METHODS
  We report a case of subcutaneous chlorpyrifos self-injection leading to a delayed cholinergic phase, prolonged coma, and severe permanent neurologic injury with electrophysiological patterns suggestive of overlapping intermediate syndrome and distal peripheral neuropathy. Time-course and severity of clinical features were not altered by either atropine or pralidoxime administration. Due to prolonged and severe alteration in consciousness, we used brain multimodal nuclear magnetic imaging and auditory cognitive event-related potentials to assess the patient's potential for awakening. Electrophysiological testing used to monitor muscle weakness showed the coexistence of 20 Hz-decremental responses in proximal muscles and severe denervation in distal muscles. Red blood cell acetylcholinesterase activity progressively normalized on day 60, while plasma butyrylcholinesterase activity remained low until day 100. Chlorpyrifos was detectable in serum until day 30 and urine metabolites for up to three months, supporting the hypothesis of a continuous chlorpyrifos release despite repeated surgical debridement. We suggest that adipose and muscle tissues acted as a chlorpyrifos reservoir. At one-year follow-up, the patient exhibited significant neuromuscular sequelae.
  
  
  CONCLUSIONS
  Subcutaneous chlorpyrifos self-injection may result in severe toxicity with prolonged neurologic injury, atypical overlapping electrophysiological patterns, and a poor final outcome.
authors.affiliation: Department of Anesthesiology and Critical Care, Multidisciplinary Intensive Care Unit, Pitié Salpêtrière Hospital, Assistance-Publique-Hôpitaux-de-Paris, UPMC (University Pierre et Marie Curie), Paris 6, France. alexis.soummer@psl.aphp.fr
authors.forename: Alexis
authors.initials: A
authors.lastname: Soummer
authors.forename: Bruno
authors.initials: B
authors.lastname: Megarbane
authors.forename: Filippo
authors.initials: F
authors.lastname: Boroli
authors.forename: Charlotte
authors.initials: C
authors.lastname: Arbelot
authors.forename: Mohamed
authors.initials: M
authors.lastname: Saleh
authors.forename: Christian
authors.initials: C
authors.lastname: Moesch
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Fournier
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Rouby
mesh_terms: D000931:Antidotes / Q000627:therapeutic use; D001285:Atropine / Q000627:therapeutic use; D001921:Brain / Q000187:drug effects / Q000473:pathology; D004390:Chlorpyrifos / Q000506:poisoning*; D006801:Humans; D007279:Injections, Subcutaneous; D007306:Insecticides / Q000506:poisoning*; D008279:Magnetic Resonance Imaging; D008297:Male; D018727:Muscarinic Antagonists / Q000627:therapeutic use; D009422:Nervous System Diseases / Q000139:chemically induced* / Q000473:pathology / Q000503:physiopathology; D011041:Poisoning / Q000188:drug therapy; D011220:Pralidoxime Compounds / Q000627:therapeutic use; D013406:Suicide, Attempted; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000931:Antidotes; D007306:Insecticides; D018727:Muscarinic Antagonists; D011220:Pralidoxime Compounds; D001285:Atropine; D004390:Chlorpyrifos; C028797:pralidoxime